Anthem among health insurers refusing to pay ER bills

Nov 28, 2018

  1. Justin Bilyj
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    Justin Bilyj Guru

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    Anyone wanna pick sides over this and start an argument?

    On Aug., 1, 2017, Brittany Cloyd of Frankfort, Kentucky, said she experienced pain "worse than childbirth." Her mother -- who had been to nursing school -- drove her to the nearest emergency room. Brittany thought her appendix had burst, but tests at the ER found she had ovarian cysts. She was given pain medication and told to follow up with her primary doctor.

    Cloyd had an Anthem Blue Cross PPO health insurance plan and thought she would get charged just a co-pay for her ER visit. Instead, 15 days later she received a letter from health insurer Anthem. "Your condition does not meet the definition of emergency," read the letter. She was responsible for the total ER bill -- $12,596.

    What Brittany endured is becoming more common in the health insurance industry, according to a Doctor Patient Rights Project (DPRP) study. It highlighted Anthem, which through its affiliated networks is the nation's largest private health insurer. The DPRP contends that Anthem has instituted an organized policy of denial designed to make its subscribers -- particularly those who are poor and reside in rural areas -- too afraid to go to an ER for fear of receiving a bill like Cloyd's, or more, for the visit.

    "The purpose of this program is to spread fear," said Dr. Ryan Stanton, a critical care and emergency medical specialist in Lexington, Kentucky.

    Anthem spokesperson Joyzelle Davis, who said she hadn't seen the study yet, issued an all-purpose response. "Anthem's Emergency Department Review aims to encourage consumers to receive care in the most appropriate setting," Davis said. "Anthem's review [of claims] aims to reduce the trend in recent years of inappropriate use of emergency departments for non-emergency use."

    Anthem did not provide specific guidelines for what would be an appropriate visit to an emergency room. But in a letter addressed to companies insured by Anthem and obtained by the DPRP, the insurer made it clear that it didn't want individuals insured by its policies to seek "care right away" at an ER when they could just as easily be treated at a doctor's office or retail health clinic.

    According to Anthem, more than a quarter of its subscribers' emergency room visits could be treated elsewhere. "If we could reduce unneeded ER visits, we can cut health care costs by $4.4 billion a year," the letter said. Consequently, Anthem noted, that would cut its member companies' costs by more than a billion dollars.


    Read the rest: ttps://www.cbsnews.com/news/anthem-among-health-insurers-refusing-to-pay-er-bills-doctors-say/
     
  2. Markthebroker
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    Well, let me throw something in the mix here. I read this article last night, and had an experience Saturday morning I think is relevant. Saturday morning I was sitting in my truck to go have breakfast with my friends. Typical weekend in the mountains. Felt 100% normal. All of the sudden I was dizzy. Within 20 minutes I was hot and cold at the same time, vomiting, shaking, dizzy with a strange feeling in my hands, feet, and head. I have never felt like this before. I don't scare easy, but I was scared. I though I might be having organ failure or a heart attack. My friends rushed me to the hospital.

    To put it in simple non medical terms, turns out I had the stomach flu, and my system decided to respond my releasing a bunch of adrenaline, hormones, chemicals and basically go bonkers. When I finally stabilized and stopped shaking, I thanked the doctors, and we both agreed I could leave and ride it out. Now that I knew I was fine, I wanted to open up the room and the doctors to someone that really needed it.

    Bottom line, I'm not a doctor, and when something like that happens, I don't want to play doctor. I didn't know what was going on. Anybody that went through that should 100% go straight to the ER. I was covered, but would Anthem have denied me? Should they have?
     
  3. VolAgent
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    VolAgent Guru

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    If you called up a doctor and reported either set of symptoms, I can all but guarantee the response would be, "If you can drive, go to the ER now! Otherwise call 911."

    Yes, there are plenty of unneeded ER visits, but intense pain is often a warning sign of something more serious. And sometimes, even when you try to avoid it, you end up there anyway. Earlier this year my son feel and cut his chin. It was bad enough it needed stitches. I tried to take him to the urgent clinic and was told to take him to the ER instead. Only the ER will do stitches.
     
    VolAgent, Nov 28, 2018
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  4. Markthebroker
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    Frankly I do see a valid side to Anthem's argument. When I was there, there was a gal there with an upset stomach, and a guy with a toothache. I remember a while back I was in the ER for a bad infection, and someone came in with a cold. None of those are ER issues.

    The other side is too, there are a lot of people coming into the ER to score painkillers, too. The doctors hand those things out like pez, feeding the problem.
     
  5. somarco
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    somarco GA Medicare Expert

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    There is no way Anthem, or any other carrier, can "win" this argument. You would be surprised the number of calls to 911 are to ask for the number of the local Papa John's Pizza.

    ER's are overcrowded by:
    - those who use the ER as their PCP
    - folks that drive by a free standing walk-in clinic and proceed to the ER
    - people who are ill or injured but something that did not require triage and emergency care

    Ending the ER copay will go a long way toward abusing the service. Or keep the copay but make it $1,000

    Before Rx copay's became the norm there was no prescription reimbursement until you hit your deductible. When employer plans implemented Rx copay's medication claims more than doubled in a years time.

    Similarly there were no doc copay's. Now people think they must have health insurance before they can see a doc.

    Health care is the only thing covered by copay's.

    I need new tires. Too bad I don't have a tire copay on my auto insurance.
     
    somarco, Nov 28, 2018
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  6. VolAgent
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    I'm all for getting the non-emergency calls out of the ER, it is better for everyone. My wife's employer added $100 to the worker's HRA for each worker and spouse who watched a 5 minute video on when and when not to go to the ER. It is a huge problem.

    But in the original example, going only by what the person said, it really does sound like a potential emergency.

    For my son, everything was subject to the deductible. I believe subsequent visits would have had an additional co-pay as well. Plenty of economic incentive to avoid the ER.
     
    VolAgent, Nov 29, 2018
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  7. somarco
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    somarco GA Medicare Expert

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    Not saying this is the case here, but some carriers deny "gray area" claims and hope they are never challenged.

    Some ER benefits language refers to a "life threatening" situation.

    When you have a kidney stone it may not be life threatening but you want to get relief ASAP.

    A ruptured or gangrenous appendix is life threatening.

    When it is your child you usually don't stop and think if this is a real emergency or one that can wait until the next day.
     
    somarco, Nov 29, 2018
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  8. leevena
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    leevena Guru

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    I agree, this is a no win for carrier. And for disclosure, I have been on the carrier side my entire career.

    Based on what was described in both situations I would agree with Anthem. By the way, below is a cut and paste from Anthems site.


    Emergency care/emergency services
    Immediate care or services needed when a person has such severe symptom that they reasonably believe the lack of immediate medical care could:
    • Place someone's health (or the health of an unborn child) at risk
    • Cause major harm to a body function or part
    Examples of an emergency include, when someone:
    • May die
    • Has chest pains
    • Cannot breathe or is choking
    • Has passed out or is having a seizure
    • Is sick from poisoning or a drug overdose
    • Has a broken bone
    • Is bleeding a lot
    • Has been attacked
    • Is about to deliver a baby
    • Has a serious injury
    • Has a severe burn
    • Has a severe allergic reaction or has an animal bite
    • Has trouble controlling behavior and without treatment is dangerous to self or others
    • If you are experiencing an emergency, call 911 or go to the closest ER. You are covered for emergency care virtually anywhere.
    If you’re not sure a health issue is an emergency, call your doctor.
     
    leevena, Nov 29, 2018
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  9. Ann H
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    Most claims are processed by computer, using diagnostic codes as guidance. The client should follow the formal appeals process, writing a simple letter telling "the rest of the story" about the excruciating pain, and asking the claims department to reverse their decision. Almost all of these types of decisions are reversed on appeal when there is an indication that the person really thought they were experiencing an emergency.
     
    Ann H, Dec 2, 2018
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  10. yorkriver1
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    I know of a situation with an ovarian cyst just as described above. Two ER visits over a couple years. Then the final one was the cyst burst, twisted the ovary and emergency surgery was required. The pain is like appendicitis, not a joke. I hope they prevail if they appeal.
     
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